Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brighton Place North during CMS and state inspections, most recent first.
Insufficient licensed nursing coverage was identified when the only scheduled LPN’s license had lapsed, yet the nurse continued working on multiple shifts across several months. Facility leadership stated they learned of the lapse only after checking the state board verification, and no Licensed Nurse Coverage policy was provided.
Food Storage and Handling Deficiencies: The facility failed to follow food safety standards in the kitchen. Observations found expired cottage cheese in a refrigerator, a staff member entering the prep area without a hair net and delivering food to a resident, and unlabeled, undated fish patties in a freezer with ice buildup. Dietary staff verified the food items should have been labeled and dated, and the facility policy required refrigerated food to be wrapped, covered, or sealed and labeled and dated.
Failure to implement EBP and a Legionella water management program. A resident with an indwelling urinary catheter, bowel incontinence, and significant behavioral/cognitive symptoms had a care plan that addressed catheter-related UTI monitoring but did not include EBP. During observation, CNA care for the catheter was done with gloves only, without a gown, and the room lacked EBP signage and PPE supplies. Staff also stated they were unaware of EBP requirements and did not have a Legionella prevention policy or system in place.
Psychotropic meds lacked required stop dates and GDR documentation for three residents. One resident with schizophrenia had routine antipsychotics and no documented GDR recommendation in the EMR; two other residents with schizoaffective disorder had multiple psychotropics, including PRN antipsychotic and antianxiety orders without stop dates. The consultant pharmacist reviews lacked GDR recommendations, and an RN stated the facility did not do GDRs.
Consultant pharmacist reviews failed to identify and report psychotropic medication irregularities for multiple residents, including missing GDR recommendations and PRN antipsychotic/anxiety orders without stop dates. Residents with schizophrenia or schizoaffective disorder were receiving routine antipsychotics, and facility staff confirmed GDRs were not being done and that the CP had not recommended them.
A facility failed to document required bed hold notifications and written transfer notices for two residents sent to the hospital. One resident had significant psychiatric and medical diagnoses, fluctuating cognition, and required assistance with ADLs; staff documented hospital transfers and later reported that bed hold paperwork was not sent or returned signed as required. Another resident with anxiety disorder and dementia was also transferred to the hospital, but the bed hold policy lacked a resident or representative signature and the record did not show written notice of the transfer, despite staff stating the representative had been told by phone.
Missing discharge and re-entry MDS for a resident who was hospitalized and later readmitted. The resident had schizophrenia, anxiety disorder, epilepsy, hypothyroidism, an indwelling urinary catheter, bowel incontinence, and behavioral/cognitive symptoms documented on the quarterly MDS. The EMR lacked the required MDS records for the hospital transfer and return, and the MDS nurse acknowledged the assessments should have been completed.
Outdated medication was found in a treatment cart when surveyors observed a resident’s Nystatin Cream had passed its expiration date. An LPN verified the expired date and removed it, and an Administrative Nurse stated the charge nurse was responsible for checking treatment expiration dates. The facility policy stated outdated drugs or biologicals shall not be used and must be returned to the dispensing pharmacy or destroyed.
Failure to use standardized criteria for antibiotic stewardship: The facility tracked infections and antibiotic courses, but an Administrative Nurse stated that no standardized criteria tool was used before antibiotics were ordered, no stop and watch system was in place, and McGeer's criteria were not understood. Staff reported signs and symptoms to physicians, who sometimes obtained urine cultures and changed antibiotics if needed, and broad-spectrum antibiotics were generally ordered to cover the infectious process.
Insufficient Licensed Nursing Coverage
Penalty
Summary
The facility failed to provide sufficient licensed nursing staff 24 hours a day for a census of 33 residents. On 10/14/25 at 3:00 PM, review of Licensed Nurse H’s employment and license verification showed the nurse’s license had lapsed on 06/30/25, yet LN H had continued to work as the only licensed nurse scheduled on multiple dates in July, August, September, and October 2025. At 3:30 PM the same day, Administrative Staff A and Administrative Nurse D stated they became aware of the lapsed license that day after checking the Kansas Board of Nursing verification, and Administrative Staff A stated LN H had been removed from the schedule until renewal was completed. Upon request, the facility did not provide a Licensed Nurse Coverage policy.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one kitchen. During observation, a kitchen refrigerator labeled #1 contained a half-full five-gallon container of cottage cheese with an expiration date of 09/20/25. A Certified Dietary Aide who was helping in the kitchen verified the finding and discarded the cottage cheese. In addition, a Social Services staff member entered the kitchen prep area without a hair net, took a plate of food from the Certified Dietary Aide, and delivered it to a resident at the dining room table; the staff member later stated she probably forgot to put on a hair net and should have. Later observation found an unlabeled and undated plastic bag of fish patties in a freezer located in the dry storage room, and the freezer had 1/2 to 1 inch of ice buildup on the inside top and each shelf. Dietary staff verified the fish patties should have been labeled and dated. The facility's Food Safety Storage Policy required refrigerated food to be wrapped, covered, or sealed and labeled and dated according to food code guidelines.
Failure to Implement EBP and Legionella Water Management Program
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter. The resident’s EMR listed schizophrenia, anxiety disorder, epilepsy, and hypothyroidism. The quarterly MDS documented modified independence for staff cognition, fluctuating inattentiveness and disorganized thinking, delusions, daily verbal behaviors directed toward others, other behaviors not directed toward others daily, and rejection of care for four to six days during the look-back period. The resident required varying levels of assistance with eating, dressing, oral care, toileting, and personal hygiene, was independent with mobility, had an indwelling urinary catheter, and was frequently incontinent of bowel. The care plan documented potential complications related to the indwelling suprapubic catheter and directed staff to assess, record, and report signs and symptoms of UTI, encourage fluid intake, cleanse drainage bags with vinegar solution, maintain a closed drainage system, and secure the bag to the leg. The care plan also directed routine urology follow-up and catheter changes as needed if dislodged or clogged, but it lacked information related to EBP. During observation, the resident was seen ambulating independently with a urine collection bag attached to the right lower leg. When CNA N emptied the catheter drainage bag, she wore gloves but did not wear a gown, and the resident’s room lacked EBP signage and gown or glove storage. CNA N stated staff used gloves for catheter care and did not wear a gown, and that gowns were available if staff wanted to use them. The facility also failed to implement a water management program for Legionella. When asked for information about the facility’s waterborne pathogen/Legionella program, Administrative Staff A stated he was not aware of the requirement and did not have a system in place. He later reported the facility lacked a Legionella prevention policy but was researching the information to implement one. Administrative Nurse D stated she was not aware of EBP requirements and that staff used standard precautions when caring for the resident’s catheter.
Psychotropic medications lacked stop dates and GDR documentation
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications for three residents had stop dates and failed to complete gradual dose reductions (GDRs) with physician documentation of the risk-versus-benefit rationale or whether continued use was clinically contraindicated. The report states the facility had a census of 33 residents and that 12 were sampled, with five reviewed for unnecessary medications. The deficiency involved Residents 2, 5, and 26, each of whom had psychotropic medication orders that lacked required duration or stop-date documentation, and each had consultant pharmacist review records that lacked GDR recommendations during the review period. Resident 2 had diagnoses of schizophrenia and a Quarterly MDS documenting a BIMS score of 14, indicating intact cognition, and independence with most ADLs. The resident received antipsychotic medication during the look-back period, and the care plan directed staff to administer psychotropic medications as ordered, monitor for side effects and effectiveness, and discuss ongoing need with the physician. The physician order dated 12/13/23 directed Asenapine 10 mg daily and Aripiprazole 10 mg at bedtime for schizophrenia. The EMR from 10/09/24 through 10/06/25 lacked documentation of a consulting pharmacist recommendation for GDR of either antipsychotic. On 10/14/25, the resident was observed ambulating with a side-to-side gait, and on 10/15/25 Administrative Nurse D verified the facility lacked documentation of GDR attempts for this resident and stated the facility did not try GDRs with residents. Resident 5 had diagnoses of schizoaffective disorder, bipolar type, severe intellectual disabilities, and hypothyroidism. The Annual MDS documented moderately impaired cognition, hallucinations, delusions, and other behavioral symptoms occurring one to three days in the look-back period, and also documented receipt of an antipsychotic, antianxiety, and antidepressant. The care plan identified psychotropic medication use related to schizoaffective disorder and bipolar type, increased fall risk related to psychotropic medications, and the need for haloperidol PRN for acute agitation and aggression. The physician orders included multiple psychotropics, including Clozaril, Invega Sustenna, Lamotrigine, Mirtazapine, Trazodone, and Haloperidol, with PRN Haloperidol 5 mg IM every 24 hours as needed for psychosis and PRN Trazodone 50 mg at bedtime for insomnia; these PRN orders lacked a duration or stop date. The consultant pharmacist monthly reviews from 10/09/24 to 10/06/25 lacked a recommendation related to GDR of psychotropic drug use or required duration for PRN antipsychotic and antianxiety medication. On 10/14/25, the resident was observed walking around the facility dressed and groomed appropriately, and on 10/15/25 Administrative Nurse D stated the facility did not do GDRs and that the consultant pharmacist had not recommended them. Resident 26 had diagnoses of schizoaffective disorder, bipolar type, constipation, and COPD. The Quarterly MDS documented intact cognition, delusions, setup/clean-up assistance with eating and showering, and independence with other functional abilities and mobility. The resident received antipsychotic and antianxiety medications, and the antipsychotic was received on a routine basis with a prior GDR attempted on 08/07/20 that the physician documented as clinically contraindicated. The Psychotropic Drug Use CAA dated 05/1/25 documented a history of hypotension, COPD, constipation, and schizoaffective disorder, but no analysis findings were completed. The care plan identified psychotropic medication use related to schizoaffective disorder, bipolar type, hoarding, self-care deficit, and a history of aggressive behavior, and directed staff to use hydroxyzine PRN for acute agitation and aggression. The physician orders included Haloperidol 5 mg twice daily, Quetiapine 100 mg twice daily, Haloperidol 5 mg every four hours PRN for psychosis without a stop or duration date, Hydroxyzine every six hours for itching and up to two tablets at bedtime, and Lorazepam 2 mg every four hours PRN for psychosis without a stop or duration date. Consultant pharmacist monthly reviews from 10/09/24 to 10/06/25 lacked a recommendation related to GDR of psychotropic drug use or required duration for PRN antianxiety or antipsychotic medication. On 10/14/25, the resident was observed up, dressed, and taking medications without problems, and on 10/15/25 Administrative Nurse D stated the facility did not do GDRs and had been working on getting stop dates for psychotropic medications.
Consultant Pharmacist Failed to Report Psychotropic Medication Irregularities
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported irregularities to the attending physician, the medical director, and the DON during monthly drug regimen reviews for multiple residents receiving psychotropic medications. The report states that the facility had a census of 33 residents and that the sample included 12 residents, with five reviewed for unnecessary medications. For the residents reviewed, the Consultant Pharmacist’s monthly reviews from 10/09/24 through 10/06/25 lacked recommendations related to gradual dose reduction (GDR) for psychotropic drugs and, for some residents, lacked required duration or stop dates for PRN antipsychotic and antianxiety medications. For one resident with schizophrenia and intact cognition, the EMR showed routine use of Asenapine and Aripiprazole for psychotropic treatment. The resident’s care plan directed staff to administer psychotropic medications as ordered, monitor for side effects and effectiveness, and discuss ongoing need with the physician. The record lacked documentation that the CP identified and reported the need for a GDR for the resident’s Aripiprazole and Asenapine. During observation, the resident was ambulatory and appeared to have a side-to-side gait. Administrative Nurse D confirmed the CP had not identified the need for a GDR and stated the facility did not try GDRs with residents. For another resident with psychotic disturbance and moderate cognitive impairment, the EMR showed routine Aripiprazole use. The care plan instructed staff to administer psychotropic medications as ordered, monitor for side effects and effectiveness, and consult with the CP and physician to consider dosage reduction when clinically appropriate at least quarterly. The resident’s EMR lacked documentation that the CP identified and reported the need for a GDR. Administrative Nurse D again stated the facility did not try GDRs with residents. A third resident with schizoaffective disorder, bipolar type, severe intellectual disabilities, and hypothyroidism had multiple psychotropic medications ordered, including Clozaril, Invega Sustenna, Lamotrigine, Mirtazapine, Trazodone, and Haloperidol, including PRN Haloperidol and PRN Trazodone orders that lacked duration or stop dates. The Consultant Pharmacist Monthly Review lacked a recommendation related to GDR of psychotropic drug use or required duration for PRN antipsychotic and antianxiety medication. The resident was observed walking around the facility and had been to the dining room for breakfast. Administrative Nurse D stated the facility had been working on getting stop dates for psychotropic medications. A fourth resident with schizoaffective disorder, bipolar type, constipation, and COPD had routine Haloperidol and Quetiapine orders, along with PRN Haloperidol and PRN Lorazepam orders that lacked stop or duration dates. The resident’s care plan addressed psychotropic use, hoarding, self-care deficit, and a history of aggressive behavior, and directed monitoring for EPS, tardive dyskinesia, effectiveness, and adverse reactions. The Consultant Pharmacist Monthly Reviews lacked a recommendation related to GDR of psychotropic drug use or required duration for PRN antianxiety or antipsychotic medication. The resident was observed up and dressed, eating breakfast, and taking medications without problems. Administrative Nurse D stated the facility did not do GDRs and the consultant pharmacist had not recommended them either.
Failure to Document Bed Hold Notifications and Transfer Notices
Penalty
Summary
The facility failed to provide required bed hold notification documentation for two residents who were transferred to the hospital. One resident had diagnoses including schizophrenia, anxiety disorder, epilepsy, and hypothyroidism, with quarterly MDS findings of modified independence for cognition, fluctuating inattentiveness and disorganized thinking, delusions, daily verbal behaviors directed toward others, and rejection of care during the look-back period. That resident also required varying levels of assistance with ADLs, had an indwelling urinary catheter, and was frequently incontinent of bowel. For the first hospitalization, staff found the resident unresponsive, obtained physician orders to send him to the ER, and called 911. He returned to the facility two days later. For a later hospitalization, the practitioner was notified of fever and a change in level of consciousness, ordered transfer to the ER, and the ambulance left with the resident. The record documented that the bed hold policy was sent to the resident’s guardian family member, but staff later stated the bed hold had not been sent for the earlier hospital admission and that the later bed hold had not been returned signed. A second resident had diagnoses of anxiety disorder and dementia, with a quarterly MDS showing a BIMS score of 12 and independence with most ADLs. That resident was transferred to the hospital, but the bed hold policy lacked the resident’s or representative’s signature, and the clinical record lacked documentation that written notice of the transfer to the hospital had been provided. Staff stated the resident was unable to sign and that the representative had been notified by telephone, but the facility did not have a signed bed hold policy or written notice documented in the record.
Missing discharge and re-entry MDS for hospitalized resident
Penalty
Summary
The facility failed to submit a required discharge MDS and re-entry MDS for a resident who was hospitalized and then returned to the facility. The resident had diagnoses including schizophrenia, anxiety disorder, epilepsy, and hypothyroidism. The resident’s quarterly MDS documented modified independence for staff cognition, fluctuating inattentiveness and disorganized thinking, delusions, daily verbal behaviors directed toward others, daily other behaviors not directed toward others, and rejection of care for four to six days during the seven-day look-back period. The resident also required varying levels of assistance with eating, dressing, oral care, toileting, and personal hygiene, was independent with mobility, had an indwelling urinary catheter, and was frequently incontinent of bowel. The resident’s EMR did not contain a discharge MDS for the hospital transfer or an entry MDS for the return to the facility. Progress notes documented that the practitioner was notified when the resident had a fever and a change in level of consciousness, and the resident was sent to the emergency room by ambulance. Another progress note documented the resident’s return to the facility. During interview, the Administrative Nurse stated she was responsible for the MDS process and that a discharge MDS should have been completed for the hospital admission and an entry MDS should have been completed upon readmission. The facility’s MDS assessment policy stated that an RN was responsible for conducting and coordinating each resident’s assessment.
Outdated Medication Found in Treatment Cart
Penalty
Summary
The facility failed to ensure that medications and biologicals were not outdated. During an initial tour of the facility treatment cart, surveyors observed that Resident 29’s Nystatin Cream, an antifungal medication used to treat fungal or yeast infections, had an expiration date that had passed. A licensed nurse verified the expiration date and removed the medication from the cart. In interview, an Administrative Nurse stated that it was the charge nurse’s responsibility to check expiration dates of treatments and reported that the expired medication had been removed from the treatment cart. The facility’s Storage of Medication policy stated that discontinued, outdated, or deteriorated drugs or biologicals shall not be used and must be returned to the dispensing pharmacy or destroyed.
Failure to Use Standardized Criteria for Antibiotic Stewardship
Penalty
Summary
The facility failed to implement protocols to avoid unnecessary and/or inappropriate antibiotic use, adverse events, and multidrug-resistant organisms, and failed to assess for infection using standardized tools and criteria before antibiotics were used. The facility had a census of 33 residents, and the sample included 12 residents. During review of the Antibiotic Stewardship Program on 10/15/25 at 09:11 AM, Administrative Nurse D provided monthly tracking logs that documented infections by type, including respiratory, urinary tract, ophthalmic, optic, skin, wounds, gastrointestinal, and other, along with the antibiotic treatment course, including start and end dates. Administrative Nurse D stated the facility had not used a standardized criteria tool before antibiotics were ordered and had not used a stop and watch system, and was unsure what McGeer's criteria were. The nurse also stated staff reported signs and symptoms to physicians, and that physicians occasionally obtained cultures for urinary tract infections and changed antibiotics if needed. Administrative Nurse D stated the physician would generally order a broad-spectrum antibiotic to ensure the infectious process was covered by the causing microorganism. The facility's undated Infection Control Program-Antibiotic Stewardship policy stated the community had established an infection prevention and control program that included protocols to establish a system for the use and monitoring of adverse effects of antibiotics, and noted that Loeb Criteria and McGeer Criteria were used as a guideline.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy On 10th Avenue | 1.9 mi | ★★★★★ | 22 | 0 |
| Countryside Health Center | 2 mi | ★★★★★ | 0 | 0 |
| Providence Living Center | 2.3 mi | ★★★★★ | 52 | 1 |
| Brighton Place West | 3.1 mi | ★★★★★ | 1 | 1 |
| Lexington Park Nursing & Post Acute Center | 4 mi | ★★★★★ | 10 | 0 |
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